VR-210 -210 (9 6b5-18) -18) 5-18)

VRV-2R1-02-160b((59-1188)) Application for Maryland Parking Placards/LLiciceennsseePPlalatteess/Residential Pole for Individuals wViRth-2a1D0i-s6abbi(l5it-y18)

MAapipl clicoamtipolnetfeodr MapaprlyiclaantdioPnatorktihneg MPloatcoarrdVse/hLicicleenAsdemPilnaitsetsra/Rtioensidential Pole for Individuals with a Disability

6601 Ritchie Highway, N.E., Glen Burnie, Maryland 21062 Attn: Disability Unit Mail completed application to the Motor Vehicle Administration

P6l6ea0s1e rReaitdcihnsietruHctiigonhswonayb,acNk.cEa.r,eGfullleynbeBfourerncoiem,pMletainrgyfloarnmd. 21062 Attn: Disability Unit

A. Customer Identifying Information - Individual with a Disability

FPirlsetaNsaemree:ad instructions on back carefully beforeMciodmdleplNeatmineg: form.

Last Name:

A. Customer Identifying Information - Individual with a Disability

FDiarstet Noaf mBiert:h:

MDriidvdelre'sNLaicmeen:se/Identification Number:

Last Name:

RDeasteidoefnBceirtSh:treet Address:

DriverC'sitLyi:cense/Identification Number: County:

State:

Zip Code:

MReasiliidnegnSctereSettreAedtdArdesdsre(sifsd: ifferent):

City:

County:

State:

Zip Code:

MIf aGiluinagrdSiatrnesehtipA,dGdrueasrsdi(aifnd'siffFeirestntN):ame:

MiddCleitNy:ame:

County:

Last Name: State:

Zip Code:

DIf aGteuaorfdBiainrtshh:ip, Guardian's First Name:

DMridvedrl'es NLiacmenes: e/Identification Number:

Last Name:

ADtatteenotifoBni:rtIh/W: e certify the statements made herein are truDeraivnedr'scoLrirceecntsteo/Itdheenbtiefisctaotifomn yN/uomurbkenr:owledge, information and belief. I/We understand it is illegal for anyone to park in any parking space designated for a person with a disability, other than an individual who has submitted and obtained a certification from the MVA, that authorizes the use of a designated parking space. I/We also understand that the individual who has been certified to have a disability must have a current disability certification card iAnttheisntoior nhe: rI/pWoesscesrtsifioynthwehsetnatuesminegntas dmisaadbeilihtyerpeliancaarredtorureplaanted.correct to the best of my/our knowledge, information and belief. I/We understand it is illegal for anyone to park in any parking space designated for a person with a disability, other than an individual who has submitted and obtained a certification from the MVA, that authorizes Ithfueruthseeroufnadedresstaignndatehdatpaaprkpilnygingspfoacr ea. dI/iWsaebaililtsyopulancdaerrdstoarnpdlathteatatnhde binydeivxiedcuuatliownhofhtahsisbaeuetnhocreizratitfieodn,tIoghivaevepeardmisisasbioilnitytommusytdhoacvteoratcourrerelenatsdeistoabtihlietyMcoertotifricVaethioicnlecard Aindhmisinoisrthraetriopnosasllemsseidoincawl hinefnorumsiantgioan dreislaatbivileitytoptlhaceaqrduaolirfipcalattioe.n requirements that established my eligibility to obtain the disability placard or plate. Additionally, I agree to release the MVA from any and all liability that may arise from the collection and storage of medical information, in the procurement of this application. This authorization

wI fiullrnthoetreuxnpdireersutnalnedssthaalltdaipsapblyiliintyg pfolarcaarddisaabnilditypplaltaecsairnd morypplaotseseasnsdiobny aerxeeecxuptiiorendoof rthI ihsaavuethreotruizranteiodna,lIl pgilvaecapredrsmainssdiopnlattoesmfyordcoacntocreltloatrioelne.ase to the Motor Vehicle Administration all medical information relative to the qualification requirements that established my eligibility to obtain the disability placard or plate. Additionally, I agree to release the MVA from any and all liability that may arise from the collection and storage of medical information, in the procurement of this application. This authorization

will not expire unless all disability placards and plates in my possession are expired or I have returned all placards and plates for cancellation.

Signature of Individual with Disability or Guardian of individual with disability

Date

B. Requested Service: q New q ReplacemeSnigt naqturLeoostf Ipnldacivaidrdu(asl) wqith SSDttiooslaleebnniliPPtyllaaoccraarGrddu((ssa))rdiqanRoef siniddeivnitdiaulaPl owlieth(AdtitsaacbhiliCtyompleted IS-022)

Date

Placard number(s):_______________________________ PPoolliiccee RReeppoorrtt ## ooff SSttoolleenn PPllaaccaarrdd((ss))::__________________________________________ JJuurriissddiiccttiioonn RReeppoorrtteedd::______________________________________________________

PBa. rRkeinqguPelsatceadrdS:ervice: q New q RepTelamcpem. Peanrtkinqg PLloasctaprdla: card(s) q Stolen Placard(sL)iceqnsReePsliadten: tial Pole (AttaMcohtCorocmycpleletPeldatIeSs-0(A2v2ai)lable in Glen Burnie Room 104 only): qPlaOcanred nuqmbTewr(os):___________________q___O__n_e____q__TPwoolice Report # of Stolen Placard(s):_q__O__n_e_______________ JurqisdOicntioen RqepoTwrteod:___________________________

PCa. rDkinsgabPilaitcyaCrde:rtification Information T(deomcpt.oPr'asrkuisneg oPnlalyca-rsde: e disability codes on backL)icense Plate:

Motorcycle Plates (Available in Glen Burnie Room 104 only):

PqleOasneenotqe ifTywoour patient has a temporaqryOdniseabiliqty, Tywouo should only recommend a tempoqraryOpnleacard for a period ofq1-6Omneonthqs. ITfwaon extension is required, your patient

cCa.nDaispapblyiliftoyr Caneratdifidcitaiotinoanl pInefroiormd aotfidoinsa(dboilictyt,ofro'sr uupsetoosnilxym- osnetehsd.isTahbisiliwtyillcroedqeuisreotnhebaacpkp)roval of the appropriate clinician. A permanent disability status should be reserved for conditions that will not improve.

TPcaYlenPaEasepOpnFloyDtfeoISrifAayBnoIuaLrdITpdYait:tioiennatlhpaesriaodteomf pdoisraabryilidtyi,safobriluitpqy, tyoPoEsuiRxsMhmoAouNnldtEhNosnT. lTyhriesqcwomiTllEmreMeqnPudOireaRAttheRemYappoprarqoryvaDplliaoscaf abthrldeedfaoVprepatreoprpaernriiaotde

of 1-6 months. If an extension is clinician. A permanent disability

required, your patient status should be

Preasteiervnet dNafomr ec:onditions that will not improve.

Disability Code:

Length of temporary disability (Temp. placard only):

TYPE OF DISABILITY:

q PERMANENT q TEMPORARY q Disqabl1edmVoeteraqn 2 mo q 3 mo q 4 mo q 5 mo q 6 mo

RTPyaeptaieesnotfnNDfaomcr tteoe:rm: pqoraLriycednisaedbilPithyy(sTiceimanp. plqacaLricdeonnsleyd:)ChDiirsoapbrialictytoCr odeq: Licensed Optometrist Length of temqpoLricaerynsdeisdabPiolidtyia(tTreismt p. placard only):

q Licensed Nurse Practitioner

q Licensed Physician's Asqsis1tamnto q 2LicmeonsedqPh3ysmicoal Thqera4pmisto q 5 mo

DTyopcetoorf'sDoorcNtourr:seqPrLaiccteitniosneedr'PshNyasmiceian(printqed)L:icensed ChSiirgonpartaucrteo:r q Licensed Optometrist

q Licensed Podiatrist

Date:

q Licensed Nurse Practitioner

q Licensed Physician's Assistant q Licensed Physical Therapist

q 6 mo

ODoffcicteorA'sdodrreNsusr:se Practitioner's Name (printed):

Signature:

Date:

COiftfyic:e Address:

County:

State:

Zip Code:

CTeitley:phone Number:

E-mail Address: County:

Medical License No.: State:

State of Issue: Zip Code: Expiration Date:

DTe. lVeephhiocnlee ONuwmnbeer rI:nformation - By sigEn-inmgaailbAodvder,eIscse:rtify that I understandMtheadticmayl Lviechenicslee mNoa.y: be parked in a parkingSstaptaecoef rIessseurev:ed for a disEabxpleirdatpioenrsDonatoen: ly when the individual named above is present and in possession of a current Disability Certification Card.

DV.eVheihcilcele#O1wner Information - By signing above, I certifMy tohattoIrucnydcelresta#n1d that my vehicle may be parked in a pMarkointgorscpyaccelere#se2rved for a disabled person only when

tThietleinNduivmidbuearl:named above is present and in possession oTfitalecNururemnbteDr:isability Certification Card.

Title Number:

Vehicle #1

Motorcycle #1

Motorcycle #2

Title Number:

Title Number:

Title Number:

6601 Ritchie Highway, N.E., Glen Burnie, Maryland 21062 For more information visit our website at mva., call 410-768-7000 or TTY for the hearing impaired: 1-800-492-4575.

6601 Ritchie Highway, N.E., Glen Burnie, Maryland 21062 For more information visit our website at mva., call 410-768-7000 or TTY for the hearing impaired: 1-800-492-4575.

Instructions: Form Purpose: An individual with a disability may use this form to request placards, license plates and/or motorcycle plates that will allow a vehicle in which he/she is riding to park in a parking space reserved for the disabled. Two types of placards are available: Temporary Placards, which are valid for a period of up to 6 months; and Permanent Parking Placards which are valid until the death of the disabled individual. An applicant may request a parking placard, license plate and motorcycle plates at the same time. See the Form Completion Instructions below.

Fee Information: There is not a fee for the placard(s). A request for a disability plate and/or motorcycle plate requires the assessment of the substitute/replacement tag fee. Please submit your completed application along with the appropriate $20.00 fee. If requesting a disability plate and/or motorcycle plate(s) and it's time to renew your vehicle registration, the registration renewal fee is also required.

Form Completion Instructions:

An individual with a permanent disability may apply for: ? One placard, or ? One regular disability plate, or ? One placard and one regular disability plate, or ? Two placards In addition, up to two motorcycle disability plates can be requested with any combination listed above.

An individual with a Temporary disability may apply for: One or two temporary placards

Parking Placard ? Complete Sections A,B and approved medical provider complete Section C. (See Note below).

License Plates or Motorcycle Plates ? Complete Sections A, B, D and approved medical provider complete Section C. (See Note below). (You may only request a disability plate or motorcycle plate(s) if the vehicle is titled in the name of the individual with a disability).

Note:

? A doctor's certification may not be required if the individual has a disability that meets the definition of code 6 or V. ? For a replacement placard, only complete Sections A and B. For replacement plates, complete Sections A, B and D. ? For temporary placards, Disability Code 10 is to be used.

Permanent Disability Codes 1-9

1. Has lung disease to such an extent that forced (respiratory) expiratory volume for one second, when measured by spirometry, is less than one liter, or arterial oxygen tension (p02) is less than 60 mm/hg on room air at rest.

2. Has cardiovascular disease limitations classified in severity as Class III or Class IV according to standards set by the American Heart Association.

3. Is unable to walk 200 feet without stopping to rest.

8. Has a permanent disability, that adversely impacts the ambulatory ability of the applicant and which is so severe that the person would endure a hardship or be subject to a risk of injury if the privileges accorded a person for whom a vehicle is specially registered were denied.

9. Has a permanent impairment of both eyes so that: 1) The central vision acuity is 20/200 or less in the better eye, with corrective glasses, or 2) There is a field defect in which the peripheral field has contracted to such an extent that the widest diameter of visual field subtends an angular distance no greater than 20 degrees in the better eye. (See Note C)

4. Is unable to walk 200 feet without the use of, or the assistance from, a brace, cane, crutch, another person, prosthetic device, or other assistance device.

5. Requires a wheelchair for mobility.

10.Temporary Placard requested D isability is not permanent but would substantially impair the person's mobility or limit or impair the person's ability to walk for at least three weeks, and is so severe that the person would endure a hardship or be subject to risk of injury if the Temporary Permit was denied.

6. Has lost an arm, hand, foot, or leg. (See Note D) 7. Has lost the use of an arm, hand, foot or leg.

V. (Reserved for use by veterans with 100% disability) The Veterans Administration has certified by letter that the applicant has a 100% service connected disability.

Notes: A. A licensed physician, licensed nurse practitioner or licensed physician's assistant may certify all qualifying conditions listed. B. A licensed chiropractor, licensed podiatrist or licensed physical therapist may certify disability codes 3 through 8 and 10. C. A licensed optometrist may certify only qualifying conditions regarding vision. D. The person with a disability may self-certify the conditions listed under Disability Code 6 by appearing in person with proper identification. In this

situation, only the disabled person's name and Disability Code must be recorded. If, however, a doctor certifies the loss of a limb, the doctor must complete all of Section C.

Visit your local MVA full service office with the completed form. If someone other than the applicant submits the application for Disability Plates or Placards they must provide a state issued ID. Applications may also be mailed with the appropriate fees to the Motor Vehicle Administration, 6601 Ritchie Highway, N.E., Glen Burnie, Maryland 21062. Attn: Disability Unit

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